Health Alt. Repiratory

Which instructions would the nurse share with the client being discharged after rhinoplasty? Avoid items that may trigger sneezing. Consume fluids at a tepid temperature. Brush the teeth thoroughly after each food intake. Sleep on the back using one pillow under the head.

Avoid items that may trigger sneezing

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? Assessing the need for suctioning Suctioning the patient's oropharynx Assessing the patient's swallowing ability Maintaining appropriate cuff inflation pressure

Suctioning the patient's oropharynx

A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately after the procedure? Monitor the patient for laryngeal edema. Assess the patient's level of consciousness. Monitor and manage the patient's level of pain. Assess the patient's heart rate and blood pressure.

Monitor the patient for laryngeal edema.

During an assessment of a patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? Laryngospasm Pulmonary edema Narrowing of the airway Overdistention of the alveoli

Narrowing of the airway

An older adult patient living alone is admitted to the hospital with pneumococcal pneumonia. Which clinical manifestation is consistent with the patient being hypoxic? Sudden onset of confusion Oral temperature of 102.3° F Coarse crackles in lung bases Clutching chest on inspiration

Sudden onset of confusion

The nurse is caring for a patient with impaired airway clearance. What is the priority nursing action to assist this patient to expectorate thick lung secretions? Humidify the oxygen as able. Administer a cough suppressant q4hr. Teach patient to splint the affected area. Increase fluid intake to 3 L/day if tolerated.

ncrease fluid intake to 3 L/day if tolerated.

A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question? 0.45% saline 0.9% saline Packed red blood cells Lactated Ringer's solution

0.45% saline Rationale: IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. IV solutions used for volume expansion for hypovolemic shock include lactated Ringer's solution and 0.9% saline. If hypovolemia is due to blood loss, blood may be administered.

At which interval are humidified oxygen systems replaced to prevent infection? 1 day 3 days 5 days 7 days

1 day Humidified oxygen delivery needs to be changed out daily to prevent infection. Every 3 to 5 days is too long to wait and may promote infection. Oxygen delivery without humidification will need to be changed out every 7 days.

The nurse is teaching a patient how to self-administer ipratropium via a metered-dose inhaler (MDI). Which instruction is most appropriate to help the patient learn the proper inhalation technique? "Avoid shaking the inhaler before use." "Breathe out slowly before positioning the inhaler." "Using a spacer should be avoided for this type of medication." "After taking a puff, hold the breath for 30 seconds before exhaling."

"Breathe out slowly before positioning the inhaler."

The provider has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? "Close lips tightly around the mouthpiece and breathe in deeply and quickly." "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."

"Close lips tightly around the mouthpiece and breathe in deeply and quickly."

A patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? "Bibasilar wheezes present on inspiration." "Diminished breath sounds in the bases of both lungs." "Fine crackles posterior right and left lower lung fields." "Expiratory wheezing scattered throughout the lung fields."

"Fine crackles posterior right and left lower lung fields."

The nurse determines that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? "I will seek immediate medical treatment for any upper respiratory infections." "I should continue to do deep breathing and coughing exercises for at least 12 weeks." "I will increase my food intake to 2400 calories a day to keep my immune system well." "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit? "I will pay less for medication because it will last longer." "More of the medication will get down into my lungs to help my breathing." "Now I will not need to breathe in as deeply when taking the inhaler medications." "This device will make it so much easier and faster to take my inhaled medications."

"More of the medication will get down into my lungs to help my breathing."

The nurse is interpreting a tuberculin skin test (TST) for a patient with end-stage renal disease due to diabetes. Which finding would indicate a positive reaction? Acid-fast bacilli cultured at the injection site 15-mm area of redness at the TST injection site 11-mm area of induration at the TST injection site Wheal formed immediately after intradermal injection

11-mm area of induration at the TST injection site

Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? 3.1 mEq/L 3.5 mEq/L 4.6 mEq/L 5.3 mEq/L

3.1 mEq/L Rationale: The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus, the patient's potassium level must be low. The only low value shown is 3.1 mEq/L.

The nurse is caring for a group of patients. Which patient is at risk of aspiration? A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery A 26-yr-old patient with continuous enteral feedings through a nasogastric tube A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

A 26-yr-old patient with continuous enteral feedings through a nasogastric tube

Which patient has early clinical manifestations of hypoxemia? A 48-yr-old patient who is intoxicated and acutely disoriented to time and place. A 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair. A 72-yr-old patient who has four new premature ventricular contractions per minute. A 94-yr-old patient who has renal insufficiency, anemia, and decreased urine output.

A 72-yr-old patient who has four new premature ventricular contractions per minute.

When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? Patient comfort Airway patency Incisional drainage Blood pressure and heart rate

Airway patency

The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? Albuterol Ipratropium bromide Salmeterol (Serevent) Beclomethasone (Qvar)

Albuterol

The patient with Parkinson's disease has a pulse oximetry reading of 72% but has no other signs of decreased oxygenation. What is the most likely explanation for the low SpO2 level? Anemia Artifact Dark skin color Thick acrylic nails

Artifact

How would the nurse position a client to practice supraglottic swallowing after a tracheostomy? In bed Upright Lying down Position of comfort

Upright

The nurse is performing a respiratory assessment. Which finding best supports the presence of impaired airway clearance? Basilar crackles Oxygen saturation of 85% Presence of greenish sputum Respiratory rate of 28 breaths/min

Basilar crackles

A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and now has exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? Pulmonary infarction Pulmonary hypertension Cytomegalovirus (CMV) Bronchiolitis obliterans (BOS)

Bronchiolitis obliterans (BOS)

The nurse is admitting a patient with a diagnosis of pulmonary embolism. Which risk factors are a priority for the nurse to assess? (Select all that apply.) Cancer Obesity Pneumonia Cigarette smoking Prolonged air travel

Cancer Obesity Cigarette smoking Prolonged air travel

A patient with a gunshot wound to the right side of the chest arrives in the emergency department with severe shortness of breath and decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? Cover the chest wound with a nonporous dressing taped on three sides. Pack the chest wound with sterile saline soaked gauze and tape securely. Stabilize the chest wall with tape and initiate positive pressure ventilation. Apply a pressure dressing over the wound to prevent excessive loss of blood.

Cover the chest wound with a nonporous dressing taped on three sides.

The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring which patient parameters? Apical pulse Daily weight Bowel sounds Deep tendon reflexes

Daily weight

The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient? Giving care will calm the patient Observing for signs of diaphoresis Evaluating the use of intercostal muscles Monitoring the patient for bilateral chest expansion

Evaluating the use of intercostal muscles

When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers? (Select all that apply.) Exercise Allergies Emotional stress Decreased humidity Upper respiratory infections

Exercise Allergies Emotional stress Upper respiratory infections

In which position should the nurse place a patient experiencing an asthma exacerbation? Supine Lithotomy High Fowler's Reverse Trendelenburg

High Fowler's

A patient with bronchiectasis has copious thick respiratory secretions. Which intervention should the nurse add to the plan of care? Use the incentive spirometer for at least 10 breaths every 2 hours. Give prescribed antibiotics and antitussives on a scheduled basis. Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours. Provide nutritional supplements that are high in protein and carbohydrates.

Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours.

While teaching a patient with asthma about the appropriate use of a peak flow meter, what should the nurse teach the patient to do? Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. Increase the dose of the long-term control medication if the peak flow numbers decrease. Use the flowmeter each morning after taking medications to evaluate their effectiveness. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.

Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse.

The nurse is evaluating if a patient understands how to safely determine whether a metered-dose inhaler (MDI) is empty. The nurse decides the patient understands this important information when the patient describes which method to check the inhaler? Place it in water to see if it floats. Keep track of the number of inhalations used. Shake the canister while holding it next to the ear. Check the indicator line on the side of the canister.

Keep track of the number of inhalations used.

The nurse is caring for a postoperative patient with impaired airway clearance. What nursing actions would promote airway clearance? (Select all that apply.) Maintain adequate fluid intake. Maintain a 15-degree elevation. Splint the chest when coughing. Have the patient use incentive spirometry. Teach the patient to cough at end of exhalation.

Maintain adequate fluid intake. Splint the chest when coughing. Teach the patient to cough at end of exhalation.

A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? Apply an external splint to the nose. Insert plastic nasal implant surgically. Humidify the air for mouth breathing. Maintain surgical packing in the nose.

Maintain surgical packing in the nose.

While ambulating a patient with metastatic lung cancer, the nurse observes a decrease in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? Continue with ambulation. Obtain a provider's order for arterial blood gas. Obtain a provider's order for supplemental oxygen. Move the oximetry probe from the finger to the earlobe.

Obtain a provider's order for supplemental oxygen.

When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse determines that the patient's nutritional status is impaired after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient? Order fruits and fruit juices to be offered between meals. Order a high-calorie, high-protein diet with six small meals a day. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet. Encourage the patient to double carbohydrate consumption and decrease fat intake.

Order a high-calorie, high-protein diet with six small meals a day.

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone after what occurs? Hypertension and pulmonary edema Oropharyngeal candidiasis and hoarseness Elevation of blood glucose and calcium levels Adrenocortical dysfunction and hyperglycemia

Oropharyngeal candidiasis and hoarseness

You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? Sodium falling to 138 mEq/L Potassium rising to 4.1 mEq/L Magnesium rising to 2.9 mg/dL Phosphorus falling to 2.1 mg/dL

Phosphorus falling to 2.1 mg/dL Rationale: Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Because hypercalcemia rarely occurs because of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal, 3.0 to 4.5 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate

During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? Pneumococcal Staphylococcus aureus Haemophilus influenzae Bacille-Calmette-Guérin (BCG)

Pneumococcal

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? Decreases chest pain Conserves energy Increases oxygen saturation Promotes elimination of CO2

Promotes elimination of CO2 Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO2. It also helps clients slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation.

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? Temperature of 98.4° F Oxygen saturation 96% Pulse rate of 72 beats/min Respiratory rate of 18/ breaths/min

Pulse rate of 72 beats/min

A patient is admitted with metabolic acidosis. Which system is not functioning normally? Renal system Buffer system Endocrine system Respiratory system

Renal system

When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? Polyuria Bradycardia Restlessness Difficulty breathing

Restlessness

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? Notify the health care provider. Administer a nitroglycerin tablet sublingually. Conduct a thorough assessment of the chest pain. Sit the patient up in bed as tolerated and apply oxygen.

Sit the patient up in bed as tolerated and apply oxygen.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which provider orders must the nurse verify have been completed before administering a dose of cefuroxime? Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum laboratory studies ordered for AM

Sputum culture and sensitivity

Which statement describes a client's tidal volume? Correct1 Tidal volume is the volume of air inhaled and exhaled with each breath. 2 Tidal volume is the amount of air remaining in the lungs after forced expiration. 3 Tidal volume is the additional air forcefully inhaled after normal inhalation. 4 Tidal volume is the additional air forcefully exhaled after normal exhalation.

Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the amount of air remaining in the lungs after forced expiration. Inspiratory reserve volume is the additional air that can be forcefully inhaled after normal inhalation. Expiratory reserve volume is the additional air that can be forcefully exhaled after normal exhalation.

A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? Oxygen tent Venturi mask Nasal cannula Oxygen-conserving cannula

Venturi mask

The nurse determines the patient with asthma has activity intolerance. What is the most likely reason for this problem? Work of breathing Fear of suffocation Effects of medications Anxiety and restlessnes

Work of breathing

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as: metabolic acidosis. respiratory acidosis. respiratory alkalosis. within normal limits.

within normal limits.

A patient with chronic obstructive pulmonary disease (COPD) becomes dyspneic at rest. The baseline ABG results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? Arterial pH 7.26 PaCO2 50 mm Hg Patient in tripod position Increased sputum expectoration

Arterial pH 7.26

The nurse is reviewing the health history of a patient with laryngeal cancer. Which finding would the nurse expect? Family history of lung cancer Recent inhalation of noxious fumes Frequent straining of the vocal cords Chronic use of alcohol and tobacco products

Chronic use of alcohol and tobacco products

When auscultating the patient's lower lungs, the nurse hears low-pitched sounds similar to blowing through a straw under water on inspiration. How should the nurse document these sounds? Stridor Vesicular Coarse crackles Bronchovesicular

Coarse crackles Rationale: Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. They are heard over all lung areas except the major bronchi. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity.

A patient has been receiving oxygen per nasal cannula while hospitalized for chronic obstructive pulmonary disease (COPD). The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? "Long-term home oxygen therapy should be used to prevent respiratory failure." "Oxygen will not be needed unless you are in the terminal stages of this disease." "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."

"You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."

When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report? 60 mL in 90 minutes 1200 mL in 24 hours 300 mL per 8-hour shift 20 mL for 2 consecutive hours

20 mL for 2 consecutive hours Rationale: The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is: 500 to 1500 mL. 1200 to 2200 mL. 2000 to 3000 mL. 3000 to 4000 mL.

2000 to 3000 mL. Rationale: Daily fluid intake and output is usually 2000 to 3000 mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.

A patient with a persistent cough is diagnosed with pertussis. What medication does the nurse anticipate administering to this patient? Antibiotic Corticosteroid Bronchodilator Cough suppressant

Antibiotic

When auscultating the patient's lower lungs, the nurse hears low-pitched sounds similar to blowing through a straw under water on inspiration. How should the nurse document these sounds? Stridor Vesicular Coarse crackles Bronchovesicular

Coarse crackles

A school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus? (Select all that apply.) Cover the nose when coughing. Obtain an influenza vaccination. Stay at home when symptomatic. Drink noncaffeinated fluids daily. Obtain antibiotic therapy promptly.

Cover the nose when coughing. Obtain an influenza vaccination. Stay at home when symptomatic.

The nurse determines that therapy with ipratropium is effective after noting which assessment finding? Decreased respiratory rate Increased respiratory rate Increased peak flow readings Decreased sputum production

Increased peak flow readings

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse understand is the reason for using this type of surgery? The patient has lung cancer. The incision will be medial sternal or lateral. Chest tubes will not be needed postoperatively. Less discomfort and faster return to normal activity.

Less discomfort and faster return to normal activity.

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding? Adventitious sounds Fine crackling sounds Vesicular breath sounds Diminished breath sounds

Vesicular breath sounds Vesicular breath sounds are normal respiratory sounds heard on auscultation as inspired air enters and leaves the alveoli. "Adventitious" is the general term for all abnormal breath sounds. Crackles heard at the end of an inspiration are associated with fluid in the alveoli. Diminished breath sounds are evidence of a reduction in the amount of air entering the alveoli; this usually is caused by obstruction or consolidation.

The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to an employee. Which question should the nurse ask before administration of this vaccine? "Are you allergic to chicken?" "Could you be pregnant now?" "Did you ever have influenza?" "Have you ever had hepatitis B?"

"Could you be pregnant now?"

The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of a fungal lung infection with Candida albicans. What patient statement indicates to the nurse that further teaching is required? "I will be given amphotericin B to treat the fungus." "I got this fungus because I am immunocompromised." "I need to be isolated from my family and friends so they won't get it." "The effectiveness of my therapy can be monitored with fungal serology titers."

"I need to be isolated from my family and friends so they won't get it."

The nurse teaches a patient with chronic obstructive pulmonary disease (COPD) how to administer fluticasone by metered-dose inhaler (MDI). Which statement indicates a correct understanding of the instructions? "I should not use a spacer device with this inhaler." "I will rinse my mouth each time after I use this inhaler." "I will feel my breathing improve over the next 2 to 3 days." "I should use this inhaler immediately if I have trouble breathing."

"I will rinse my mouth each time after I use this inhaler."

The nurse teaches a patient about the use of budesonide intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? "My liver function will be checked with blood tests every 2 to 3 months." "The medication will decrease the congestion within 3 to 5 minutes after use." "I may develop a serious infection because the medication reduces my immunity." "I will use the medication every day of the season whether I have symptoms or not."

"I will use the medication every day of the season whether I have symptoms or not."

The nurse teaches a patient with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? "I should avoid using ibuprofen for pain and discomfort." "It is important for me to take my blood pressure medication every day." "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." "If I get a nosebleed, I will lie down flat and raise my feet above my heart."

"If I get a nosebleed, I will lie down flat and raise my feet above my heart."

Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching about the use of an ipratropium inhaler? "I should wait at least 1 to 2 minutes between each puff of the inhaler." "I can rinse my mouth following the two puffs to get rid of the bad taste." "Because this medication is not fast acting, I cannot use it in an emergency if my breathing is worse." "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."

"If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."

An 18-yr-old patient at the student health center with a history of frequent lung and sinus infections has manifestations consistent with undiagnosed CF. Which information would be accurate for the nurse to include when teaching the patient about a scheduled sweat chloride test? "Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF." "The test measures the amount of sodium chloride in your postexercise sweat." "If sweating occurs after an oral dose of pilocarpine, the test result for CP is positive." "If the sweat chloride test result is positive on two occasions, genetic testing will be necessary."

"Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF."

The nurse teaches a patient with a pulmonary embolism how to administer enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? "I need to take this medicine with meals." "The medicine will be prescribed for 10 days." "I will inject this medicine into my upper arm." "The medicine will dissolve the clot in my lung."

"The medicine will be prescribed for 10 days."

When a client has a superficial tumor involving only 1 vocal cord, which surgery would the nurse anticipate? Cordectomy Tracheotomy Total laryngectomy Oropharyngeal resections

A cordectomy is a surgical procedure performed in clients with laryngeal cancer; this surgery involves the removal of a vocal cord. A tracheotomy is a surgical incision in the trachea for the purpose of establishing an airway. A total laryngectomy is a surgical procedure in which the entire larynx, hyoid bone, strap muscles, and 1 or 2 tracheal rings are removed. A nodal neck dissection is also done in a total laryngectomy if the nodes are involved. An oropharyngeal resection is a surgical procedure performed to treat cancer of the oropharynx.

Which test result identifies that a patient with asthma is responding to treatment? An increase in CO2 levels A decreased exhaled nitric oxide A decrease in white blood cell count An increase in serum bicarbonate levels

A decreased exhaled nitric oxide

The nurse is caring for a patient with a fever due to pneumonia. What assessment data does the nurse obtain that correlates with the patient having a fever? (Select all that apply.) A temperature of 101.4° F Heart rate of 120 beats/min Respiratory rate of 20 breaths/min A productive cough with yellow sputum Reports of unable to have a bowel movement for 2 days

A temperature of 101.4° F Heart rate of 120 beats/min A productive cough with yellow sputum

A 45-yr-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which manifestation would be an early indication of an exacerbation of asthma? Anxiety Cyanosis Bradycardia Hypercapnia

Anxiety

During admission of a patient diagnosed with non-small cell lung cancer, the nurse questions the patient related to a history of which risk factors for this type of cancer? (Select all that apply.) Asbestos exposure Exposure to uranium Chronic interstitial fibrosis History of cigarette smoking Geographic area in which they were born

Asbestos exposure Exposure to uranium History of cigarette smoking

The nurse is caring for a patient admitted to the medical unit with hypokalemia. The best foods to offer the patient are? (Select all that apply.) Apple Banana Orange juice Chocolate milk Cooked broccoli

Banana Orange juice Chocolate milk Cooked broccoli Rationale: Milk products, oranges, and bananas are all high in potassium. Cooked broccoli is high in potassium. Apples are low in potassium.

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? Water-seal chamber has 5 cm of water No new drainage in collection chamber Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site

Chest tube with a loose-fitting dressing

When assessing the patient in acute respiratory distress, what should the nurse expect to observe? (Select all that apply.) Cyanosis Tripod position Kussmaul respirations Accessory muscle use Increased AP diameter

Cyanosis Accessory muscle use Rationale: Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore, it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from chronic obstructive pulmonary disease, cystic fibrosis, or with advanced age.

When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included about the effects of smoking on the lungs? Smoking causes a hoarse voice. Cough will become nonproductive. Decreased alveolar macrophage function. Sense of smell is decreased with smoking.

Decreased alveolar macrophage function.

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with chronic obstructive pulmonary disease (COPD) are successful based on which finding? Absence of dyspnea Improved mental status Effective and productive coughing PaO2 within normal range for the patient

Effective and productive coughing

Assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? Acute respiratory failure Secondary respiratory infection Fluid volume excess from cor pulmonale Pulmonary edema caused by left-sided heart failure

Fluid volume excess from cor pulmonale

When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands the manifestations of the disease are related to what process? An overproduction of the antiprotease a1-antitrypsin Hyperinflation of alveoli and destruction of alveolar walls Hypertrophy and hyperplasia of goblet cells in the bronchi Collapse and hypoventilation of the terminal respiratory unit

Hyperinflation of alveoli and destruction of alveolar walls

A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? IV antibiotic therapy will be started as soon as possible. Lobectomy surgery is usually needed to drain the abscess. Oral antibiotics will be used until there is evidence of improvement. Culture and sensitivity tests are needed for 1 year after resolving the abscess.

IV antibiotic therapy will be started as soon as possible.

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation would the nurse expect to find? Hyperresonance on percussion Vesicular breath sounds in all lobes Increased vocal fremitus on palpation Fine crackles in all lobes on auscultation

Increased vocal fremitus on palpation

When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included? Increasing dyspnea Temperature below 98.6° F Decreased sputum production Unable to drink 3 L of low-sodium fluids

Increasing dyspnea

The nurse supervises a team including another registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and unlicensed assistive personnel (UAP) on a medical unit. The team is caring for many patients with respiratory problems. In what situation should the nurse intervene with teaching for a team member? LPN/VN obtained a pulse oximetry reading of 94% but did not report it. UAP report to the nurse that the patient is reporting of difficulty breathing. RN taught the patient about home oxygen safety in preparation for discharge. LPN/VN changed the type of oxygen device based on arterial blood gas results.

LPN/VN changed the type of oxygen device based on arterial blood gas results.

The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. What should the nurse assess this patient for? Cough reflex Mucociliary clearance Reflex bronchoconstriction Ability to filter particles from the air

Mucociliary clearance

The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? Teach the patient to cough and deep breathe. Take the temperature, pulse, and respiratory rate. Obtain a sputum specimen for culture and Gram stain. Check the patient's oxygen saturation by pulse oximetry.

Obtain a sputum specimen for culture and Gram stain.

When teaching the patient with cystic fibrosis about diet and medications, what priority information should you include? Fat-soluble vitamins and dietary salt should be avoided. Insulin may be needed with a diabetic diet if diabetes develops. Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. Distal intestinal obstruction syndrome (DIOS) can be treated with increased water.

Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed.

An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? Perform a comprehensive health history with the patient to review prior respiratory problems. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

The nurse is caring for a patient with unilateral lung cancer. What is the priority nursing action to enhance oxygenation in this patient? Positioning patient on right side Maintaining adequate fluid intake Positioning patient with "good lung" down Performing postural drainage every 4 hours

Positioning patient with "good lung" down Rationale: Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

The nurse teaches pursed-lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? Loosening secretions so that they may be coughed up more easily Promoting maximal inhalation for better oxygenation of the lungs Preventing bronchial collapse and air trapping in the lungs during exhalation Increasing the respiratory rate and giving the patient control of respiratory patterns

Preventing bronchial collapse and air trapping in the lungs during exhalation

A patient has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy cannula care? Level of consciousness Quality of breath sounds Presence of the gag reflex Tracheostomy cuff pressure

Quality of breath sounds

The nurse is teaching a patient how to self-administer beclomethasone, 2 puffs inhaled every 6 hours. What should the nurse teach the patient to do to prevent oral infection while taking this medication? Chew a hard candy before the first puff of medication. Ask for a breath mint after the second puff of medication. Rinse the mouth with water before each puff of medication. Rinse the mouth with water after the second puff of medication.

Rinse the mouth with water after the second puff of medication.

The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? IV fluids Biofeedback therapy Systemic corticosteroids Pulmonary function testing

Systemic corticosteroids

The nurse is caring for a patient admitted for exacerbation of chronic obstructive pulmonary disease. The patient develops severe dyspnea at rest, with an increase in respiratory rate from 26 to 44 breaths/min. Which action by the nurse would be the most appropriate? Have the patient perform huff coughing. Perform chest physiotherapy for 5 minutes. Teach the patient to use pursed-lip breathing. Instruct the patient in diaphragmatic breathing.

Teach the patient to use pursed-lip breathing.

The nurse observes clear nasal drainage in a patient newly admitted with facial trauma with a nasal fracture. What is the nurse's priority action? Test the drainage for the presence of glucose. Suction the nose to maintain airway clearance. Document the findings and continue monitoring. Apply a drip pad and reassure the patient this is normal.

Test the drainage for the presence of glucose.

Before discharge, the nurse discusses activity levels with a 61-yr-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness? Slightly increase activity over the current level. Swim for 10 min/day, gradually increasing to 30 min/day. Limit exercise to activities of daily living to conserve energy. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

The nurse is caring for a patient with an acute exacerbation of asthma. After initial treatment, what finding indicates to the nurse that the patient's respiratory status is improving? Wheezing becomes louder. Cough remains nonproductive. Vesicular breath sounds decrease. Aerosol bronchodilators stimulate coughing.

Wheezing becomes louder.

After auscultating the chest, how will the nurse document findings of bilateral, high-pitched, continuous whistling sounds heard during each expiration? Crackles Wheezes Rhonchus Pleural friction rub

Wheezing, an adventitious breath sound, is a high-pitched continuous whistling that does not clear with coughing. Crackles are popping, discontinuous sounds caused by air moving into previously deflated airways. Rhonchus is a lower-pitched, coarse, continuous snoring sound that arises from the large airways. Pleural friction rub is a loud, rough, grating sound produced by inflammation of the pleural lining.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

A patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? "Bibasilar wheezes present on inspiration." "Diminished breath sounds in the bases of both lungs." "Fine crackles posterior right and left lower lung fields." "Expiratory wheezing scattered throughout the lung fields."

"Fine crackles posterior right and left lower lung fields." Rationale: Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration.

When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give? 1 "You developed an infection that requires antibiotics." 2 "This is a highly contagious infection requiring isolation." 3 "An infection you had before beginning treatment has flared up." "Your infection occurred because of exposure to a health care facility. "

"Your infection occurred because of exposure to a health care facility. " A health care-acquired infection is contracted during treatment in a health care facility, such as a hospital or nursing home. Both community-acquired and health care-acquired infections may require antibiotics. Community-acquired and health care-acquired infections may require isolation. An infection that occurred before hospitalization would be called a community-acquired infection.

What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? Fingernails Chest excursion Spinal curvatures Respiratory pattern

Fingernails Rationale: Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.

A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis? 0.9% sodium chloride 25% albumin solution Lactated Ringer's solution 5% dextrose in 0.45% saline

25% albumin solution Rationale: After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's solution, and 5% dextrose in 0.45% saline will not be effective for this action.

The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? 2 minutes 5 minutes 10 minutes 15 minutes

5 minutes Rationale: After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.

The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis? A patient with a traumatic brain injury A patient with type 1 diabetes mellitus A patient with acute respiratory failure A patient with nasogastric tube suction

A patient with nasogastric tube suction Rationale: Excessive nasogastric suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? Dull sound on percussion Vocal fremitus on palpation Rales with rhonchi on auscultation Absence of breath sounds on auscultation

Absence of breath sounds on auscultation The left lung is collapsed; therefore there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

The nurse described a client's abnormal breath sounds and included crackles, rhonchi, wheezes, and pleural friction rubs. Which breath sounds did the nurse hear? 1 Vesicular Incorrect2 Bronchial Correct3 Adventitious 4 Bronchovesicula

Adventitious sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched and resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium pitch and intensity and are heard over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae.

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. The nurse suspects that the patient may be experiencing what complication? Air embolism Catheter occlusion Insertion site trauma Precipitate build up in lumen

Air embolism Rationale: The cap off the central line could allow entry of air into the circulation, causing an air embolus. Catheter occlusion, precipitate build up in lumen manifest with sluggish infusions. Insertion site trauma manifests with edema near the insertion site and dysrhythmias.

Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough? Select all that apply. One, some, or all responses may be correct. Type of employment Presence of ear pain History of tobacco use Oral hygiene practices Amount of alcohol intake

All

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. One, some, or all responses may be correct. Mold Cold air Pet dander Air pollution Cigarette smoke

All

Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply. One, some, or all responses may be correct. Facial edema Septal deviation Clear nasal drainage Oxygen saturation 89% Bilateral periorbital bruising

All Facial edema and septal deviation indicate that the client has sustained facial injuries. Clear nasal drainage is an indication of a cerebrospinal fluid leak, and the nurse would immediately report the finding and send the drainage to be tested for glucose. An oxygen level of 89% would be reported to the health care provider as it could indicate nonvisible injuries. "Raccoon eyes" or bilateral periorbital bruising indicates a basilar skull fracture and requires immediate medical treatment.

A patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas exchange in the lung and tissue oxygenation? Thoracentesis Bronchoscopy Arterial blood gases Pulmonary function tests

Arterial blood gases Rationale: Arterial blood gases are used to assess the efficiency of gas exchange in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.

The patient with Parkinson's disease has a pulse oximetry reading of 72% but has no other signs of decreased oxygenation. What is the most likely explanation for the low SpO2 level? Anemia Artifact Dark skin color Thick acrylic nails

Artifact Rationale: Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question.

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. Which immediate action would the nurse implement? Auscultate the lungs. Obtain arterial blood gases. Notify the health care provider. Apply pressure to the abdomen.

Auscultate the lungs. Always assess the client first to determine if the lung sounds are indicative of fluid overload. When respiratory distress occurs, possibly from pressure of the dialysate on the diaphragm, respiratory status and vital signs should be assessed. The health care provider should be notified and arterial blood gases should be obtained after immediate action is taken. Never apply pressure to the abdomen, as that could worsen the respiratory status.

The nurse is performing a focused respiratory assessment of a patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? Auscultation of bilateral breath sounds Percussion of anterior and posterior chest wall Palpation of the chest bilaterally for tactile fremitus Inspection for anterior and posterior chest expansion

Auscultation of bilateral breath sounds Rationale: Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment.

A frail older adult patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? Bases of the posterior chest area Apices of the posterior lung fields Anterior chest area above the breasts Midaxillary on the left side of the chest

Bases of the posterior chest area Rationale: Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case, the nurse should start at the bases.

A patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? Bilateral erythema of especially large tonsils Temperature 102.2° F, diaphoresis, and chills Contraction of neck muscles during inspiration β-Hemolytic streptococcus in the throat culture

Contraction of neck muscles during inspiration

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? Cerebral palsy Cystic fibrosis Muscular dystrophy Multiple sclerosis

Cystic Fibrosis The early symptom of cystic fibrosis is meconium ileus, which is impacted stool in the newborn. Thick mucous secretions, salty sweat, and difficulty gaining weight because of high caloric demands are characteristics of the condition. Cerebral palsy is a motor disorder caused by damage to the brain. Muscular dystrophy is a muscular disorder. Multiple sclerosis is a condition with progressive disintegration of the myelin sheath.

After swallowing, a 73-yr-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormal finding? Decreased response to hypercapnia Decreased number of functional alveoli Increased calcification of costal cartilage Decreased respiratory defense mechanisms

Decreased respiratory defense mechanisms

Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? Prevents bronchial spasm Decreases air trapping in lung Improves alveolar surface area Strengthens diaphragmatic contraction

Decreases air trapping in lung. Pursed-lip breathing provides positive pressure in the airways during expiration, prolonging expiration and decreasing the air trapping, which is characteristic of emphysema. Pursed-lip breathing will not decrease bronchospasm, which is characteristic of asthma. Alveolar surface area is not changed by pursed-lip expiration. Diaphragmatic contraction is not strengthened by pursed-lip breathing.Test-

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? Fluid movement from the blood vessels into the cells Fluid movement from the interstitial space into the cells Fluid movement from the interstitial spaces into the plasma Fluid movement from the blood vessels into interstitial spaces

Fluid movement from the interstitial spaces into the plasma Rationale: In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

Which action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter? Change the injection cap after the administration of IV medications. Use a 5-mL syringe to flush the catheter between medications and after use. During removal of the catheter, have the patient perform the Valsalva maneuver. If resistance is met when flushing, use the push-pause technique to dislodge the clot.

During removal of the catheter, have the patient perform the Valsalva maneuver.

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect to teach the patient about? Nasal packing Epistaxis balloon Gastrostomy tube Peripheral skin care

Gastrostomy tube

A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? Limit foods high in potassium. Calcium gluconate IV piggyback. Give a potassium-sparing diuretic daily. Administer intravenous insulin and glucose.

Give a potassium-sparing diuretic daily. Rationale: Potassium-sparing diuretics inhibit the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. A potassium-sparing diuretic is contraindicated in a patient with hyperkalemia. Management of patients with hyperkalemia may include limiting foods high in potassium, administering IV insulin and glucose, administering IV calcium gluconate, changing to potassium-wasting diuretics (e.g., furosemide [Lasix]), hemodialysis, administering sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? Age older than 80 years History of upper respiratory infections Chronic obstructive pulmonary disease (COPD) History of a severe allergic reaction to the vaccine

History of a severe allergic reaction to the vaccine

A patient has metabolic acidosis secondary to type 1 diabetes. What physiologic response should the nurse expect to assess in the patient? Vomiting Increased urination Decreased heart rate Increased respiratory rate

Increased respiratory rate Rationale: When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.

When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient? (Select all that apply.) Is it hard for you to fall asleep? Do you awaken abruptly during the night? Do you sleep more than 8 hours per night? Do you need to sleep with the head elevated? Do you often need to urinate during the night?

Is it hard for you to fall asleep? Do you awaken abruptly during the night? Do you need to sleep with the head elevated?

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? Slow the rate to keep vein open until next bag is due at noon. Notify the health care provider and complete an incident report. Listen to the patient's lung sounds and assess respiratory status. Assess the patient's cardiovascular status by checking pulse and blood pressure.

Listen to the patient's lung sounds and assess respiratory status. Rationale: After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and you should assess the patient's respiratory status and lung sounds as the priority action and then notify the health care provider for further orders.

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. You should hold a medication from which classification until you consult with the health care provider? Antibiotics Loop diuretics Bronchodilators Antihypertensives

Loop diuretics Rationale: Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus, administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.

A patient with dehydration is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions? (Select all that apply.) Lung sounds Bowel sounds Blood pressure Serum sodium level Serum potassium level

Lung sounds Blood pressure Serum sodium level Rationale: Blood pressure, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the tracheostomy tube is expelled by coughing. What is the priority action by the nurse? Suction the tracheostomy opening. Maintain the airway with a sterile hemostat. Use an Ambu bag and mask to ventilate the patient. Insert the tracheostomy tube obturator into the stoma.

Maintain the airway with a sterile hemostat.

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? Select all that apply. One, some, or all responses may be correct. Emptying the drainage system when full Keeping the drainage system at heart level Notifying the health care provider of drainage greater than 50 mL/h Marking the time on the drainage unit every shift Laying the drainage system on its side during transport

Marking the time on the drainage unit every shift The nurse would mark the drainage system every shift to determine the amount of drainage. The drainage system is a closed system, so the nurse would switch out the drainage system when it is full. Emptying the system would break sterility. The drainage system should remain below chest level to prevent fluid from backing up into the lungs. The nurse would notify the health care provider if drainage is greater than 100 mL/h. The nurse would keep the drainage system upright.

The patient seeks relief from the symptoms of an upper respiratory infection (URI) lasting for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? Coughing Fever, chills Dust allergy Maxillary pain

Maxillary pain

You are admitting a patient who reports abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic alkalosis Rationale: Because gastric secretions are rich in HCl acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.

Which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site? 1 Sterile saline 2 Steroid cream 3 Oil-based lubricant Correct4 Mild soap and water

Mild soap and water Mild soap and water are used to cleanse the stoma site. Sterile saline, a humidifier, or pans of water can be used to humidify the air entering the stoma. There is no need to use steroid cream at the site unless instructed by the health care provider. Non-oil-based, rather than oil-based, lubricants can be used as needed for lubrication of the site.Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which nursing intervention is most appropriate when caring for a patient with dehydration? Monitor skin turgor every shift. Auscultate lung sounds every 2 hours. Monitor daily weight and intake and output. Encourage the patient to reduce sodium intake.

Monitor daily weight and intake and output. Rationale: Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume.

After reviewing information about oxygenation for 4 clients with chronic obstruction pulmonary disease, which client will the nurse plan to teach about use of home long-term continuous oxygen therapy? Partial pressure of oxygen (PaO2) of 72; peripheral capillary oxygen saturation (SpO2) of 96 PaO2 of 60; SpO2 of 90 PaO2 of 55; SpO2 of 88 PaO2 of 70; SpO2 of 92

PaO2 of 55; SpO2 of 88 A PaO2 of 55 and SpO2 of 88 indicate hypoxemia and that long-term oxygen therapy is needed. The values PaO2 72 and SpO2 96 indicate adequate oxygenation. The values PaO2 60 and SpO2 90 are adequate and the client would not require oxygen therapy. The values PaO2 70 and SpO2 92 are adequate and do not indicate a need for oxygen therapy.

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? Fully compensated respiratory alkalosis Partially compensated respiratory acidosis Normal acid-base balance with hypoxemia Normal acid-base balance with hypercapnia

Partially compensated respiratory acidosis Rationale: A low pH (normal, 7.35 to 7.45) indicates acidosis. In a patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal, 35 to 45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.

After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? Bronchospasm Pneumothorax Pulmonary edema Respiratory acidosis

Pneumothorax Rationale: Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.

A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? Thoracentesis Pulmonary angiogram CT scan of the patient's chest Positron emission tomography (PET)

Positron emission tomography (PET)

A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? Thoracentesis Pulmonary angiogram CT scan of the patient's chest Positron emission tomography (PET)

Positron emission tomography (PET) Rationale: PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.

A patient is admitted for joint replacement surgery and has a permanent tracheostomy. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Suction the tracheostomy. Check stoma site for skin breakdown. Complete tracheostomy care using sterile technique. Provide oral care with a toothbrush and tonsil suction tube

Provide oral care with a toothbrush and tonsil suction tube.

Which actions would the nurse take to obtain subjective data about a client's respiratory status? Select all that apply. One, some, or all responses may be correct. 1 Palpate the chest and back for masses. Correct2 Question the client about shortness of breath. 3 Check the hematocrit and hemoglobin values. 4 Inspect the skin and nails for integrity and color. Correct5 Ask the client about color and quantity of sputum.

Question the client about shortness of breath Ask the client about color and quantity of sputum. Subjective data is collected directly from the client. During the respiratory assessment, the nurse would ask the client about any shortness of breath and about the color and quantity of any sputum produced. Objective data is collected by the nurse through physical examination and laboratory reports. The nurse would palpate the chest and back for masses while collecting objective data during the physical examination. The nurse checks the hematocrit and hemoglobin values while collecting objective diagnostic data. The nurse inspects the client's skin and nails for integrity and color to determine oxygenation of tissues.Test-Taking Tip: The nurse would undertake certain interventions during focused respiratory assessment. Make sure you read all the statements before choosing the correct option.

Which statements are appropriate to include when teaching a patient about hypercalcemia? (Select all that apply.) Have patient restrict fluid intake to less than 2000 mL/day. Renal calculi may occur as a complication of hypercalcemia. Weight-bearing exercises can help keep calcium in the bones. The patient should increase daily fluid intake of 3000 to 4000 mL. Any heartburn can be managed with an as needed calcium-containing antacid.

Renal calculi may occur as a complication of hypercalcemia. Weight-bearing exercises can help keep calcium in the bones. The patient should increase daily fluid intake of 3000 to 4000 mL. Rationale: A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.

After percussing a client's posterior chest and hearing low-pitched hollow sounds over the whole chest, how will the nurse document the finding? 1 Dull 2 Flat 3 Tympanic Correct4 Resonance

Resonance Resonance is a low-pitched hollow sound normally heard over the air-filled lungs during percussion in healthy individuals. Dullness is a medium-pitched "thud-like" sound that might be heard with problems like lung consolidation due to pneumonia. Flatness is a high-pitched and short duration sound that might be heard over a pleural effusion. Tympanic sounds are high-pitched and musical; tympany might be heard over a pneumothorax.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis. The pH indicates acidosis; the PCO2 level is the parameter for respiratory function. The expected PCO2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.

The nurse is caring for a patient with a tracheostomy. What is the priority nursing assessment for this patient? Electrolyte levels and daily weights Assessment of speech and swallowing Respiratory rate and oxygen saturation Pain assessment and assessment of mobility

Respiratory rate and oxygen saturation

The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What other manifestations should the nurse expect to observe in this patient? Restlessness, tachypnea, tachycardia, and diaphoresis Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis Combativeness, retractions with breathing, cyanosis, and decreased output Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

Restlessness, tachypnea, tachycardia, and diaphoresis

The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What other manifestations should the nurse expect to observe in this patient? Restlessness, tachypnea, tachycardia, and diaphoresis Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis Combativeness, retractions with breathing, cyanosis, and decreased output Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

Restlessness, tachypnea, tachycardia, and diaphoresis Rationale: With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue are later manifestations of inadequate oxygenation.

You receive a provider's prescription to change a patient's IV from 5% dextrose in 0.45% saline with 40 mEq KCl/L to 5% dextrose in 0.9% saline with 20 mEq KCl/L. Which serum laboratory values best support the rationale for this IV order change? Sodium, 136 mEq/L; potassium, 3.6 mEq/L Sodium, 145 mEq/L; potassium, 4.8 mEq/L Sodium, 135 mEq/L; potassium, 4.5 mEq/L Sodium, 144 mEq/L; potassium, 3.7 mEq/L

Sodium, 135 mEq/L; potassium, 4.5 mEq/L Rationale: The normal range for serum sodium is 136 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore, for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and would begin with which aspect of care? The disease process and breathing exercises How to control or prevent respiratory infections Using aerosol therapy, especially nebulizers Priorities when performing everyday activities

The disease process and breathing exercises.

Which amount is the normal value of a client's inspiratory reserve volume? 1 0.5 L 2 1.0 L 3 1.5 L Correct4 3.0 L

The normal value of inspiratory reserve volume is 3.0 L. The normal value of tidal volume is 0.5 L. The normal value of expiratory reserve volume is 1.0 L. The normal value of residual volume is 1.5 L.

You are caring for a patient admitted with diabetes, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient? (Select all that apply.) The potassium level may be increased if the patient has nephropathy. The patient has been eating excessive amounts of foods that increase potassium levels. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. There may be excess potassium being released into the blood as a result of massive blood transfusion. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

The potassium level may be increased if the patient has nephropathy. There may be excess potassium being released into the blood as a result of massive blood transfusion. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

A patient is being discharged from the emergency department after being treated for epistaxis. In teaching first aid measures in the event the epistaxis would recur, what measures should the nurse suggest? (Select all that apply.) Tilt patient's head backwards. Apply ice compresses to the nose. Tilt head forward while sitting upright. Pinch the entire soft lower portion of the nose. Lying down until 15 minutes after the bleeding ceases

Tilt head forward while sitting upright. Pinch the entire soft lower portion of the nose.

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen? To prevent dyspnea To prevent cyanosis To increase oxygen concentration to heart cells To increase oxygen tension in the circulating blood

To increase oxygen concentration to heart cells Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.

Which parameter describes the maximum volume of air a client's lungs may contain? 1 Vital capacity Correct2 Total lung capacity 3 Inspiratory capacity 4 Functional residual capacity

Total lung capacity is the maximum volume of air that the lungs can contain. Vital capacity is the maximum volume of air that can be exhaled after maximum inspiration. Inspiratory capacity is the maximum volume of air that can be inhaled after maximum expiration. Functional residual capacity is the volume of air remaining in the lungs at the end of normal exhalation.

The nurse is palpating the patient's chest during a focused respiratory assessment in the emergency department. Which finding is a medical emergency? Increased tactile fremitus Diminished chest movement Tracheal deviation to the left Decreased anteroposterior (AP) diameter

Tracheal deviation to the left

The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? Electromyography Intraoral electrolarynx Neck type electrolarynx Transesophageal puncture

Transesophageal puncture Rationale: The transesophageal puncture provides a fistula between the esophagus and trachea with a one-way valved prosthesis to prevent aspiration from the esophagus to the trachea. Air moves from the lungs and vibrates against the esophagus, and words are formed with the tongue and lips as the air moves out the mouth. The electromyography and both electrolarynx methods produce low-pitched mechanical sounds.

A client presents with hemoptysis. The nurse recalls that the clinical manifestation is associated with which disease? Anemia Pneumonia Tuberculosis Leukocytosis

Tuberculosis Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea

How would the nurse position a client with epistaxis? Supine Side-lying Upright leaning forward Sitting with the head tipped backward

Upright leaning forward A client with a nosebleed should be positioned upright leaning forward to prevent aspiration and decrease blood flow to the nose. The supine position increases the risk for aspiration or swallowing blood. The side-lying position will increase blood flow to the nose more than sitting upright and may increase aspiration risk. Having the head tipped backward increases the risk for aspiration or swallowing blood.

Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. Which term would be used when documenting this assessment finding? Fine crackles Adventitious sounds Vesicular breath sounds Diminished breath sounds

Vesicular breath sounds Vesicular breath sounds are expected respiratory sounds heard on auscultation as inspired air enters and leaves alveoli. Fine crackles are faint crackling sounds heard at the end of inspiration; they are associated with pulmonary edema. "Adventitious sounds" is a general term for all abnormal breath sounds. Diminished breath sounds are evidence of a decreased amount of air entering the alveoli; this usually is caused by obstruction or consolidation.Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? (Select all that apply.) Weakness Paresthesia Facial spasms Muscle tremors Depressed reflexes

Weakness Depressed reflexes Rationale: Signs of hypercalcemia are lethargy, fatigue, weakness, depressed reflexes, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.

The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient's lung sounds in the lower lobes are diminished. The nurse knows this could be related to the occurrence of: pain. atelectasis. pneumonia. pleural effusion.

atelectasis.

The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient's lung sounds in the lower lobes are diminished. The nurse knows this could be related to the occurrence of: pain. atelectasis. pneumonia. pleural effusion.

atelectasis. Rationale: After surgery, there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case.

The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? Frequency, family history, hematemesis Cough sound, sputum production, pattern Weight loss, activity tolerance, orthopnea Smoking status, medications, residence location

ough sound, sputum production, pattern Rationale: The sound of the cough, sputum production and description, and the pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for chronic obstructive pulmonary disease, and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems but are not as important when dealing with a cough.